External Site Reviews
MSHN has external quality reviews completed by the Michigan Department of Health and Human Services (MDHHS) and the Health Services Advisory Group (HSAG). To comply with requirements of the Center for Medicare and Medicaid Services (CMS), MDHHS completes a review of the PIHPs for services provided under the Habilitation Supports Waiver (HSW) and Substance Use Services. Also to comply with CMS requirements, MDHHS contracts with HSAG to measure and report on performance to assess the quality and appropriateness of care and services provided to members. HSAG completes three separate reviews: Performance Measure Validation (PMV), Performance Improvement Project (PIP) and the Compliance Monitoring review.
HSAG Performance Measure Validation (PMV) Review
The purpose of Performance Measure Validation (PMV) review is to assess the accuracy of performance indicators reported by the PIHPs and to determine the extent to which performance indicators reported by the PIHPs follow state specifications and reporting requirements.
HSAG Compliance Monitoring Review
The purpose of Compliance Monitoring review is to determine the PIHP’s compliance with the standards set forth in 42 CFR §438—Managed Care Subpart D and the quality assessment and performance improvement requirements described in 42 CFR §438.330.
HSAG Performance Improvement Project
The purpose of the Performance Improvement Project review is to comply with the MDHHS requirement that the PIHP conduct and submit performance improvement projects (PIPs) annually to comply with the Balanced Budget Act of 1997 (BBA), which states that the quality of health care delivered to Medicaid enrollees in PIHPs must be tracked, analyzed, and reported annually. PIPs provide a structured method of assessing and improving the processes, and thereby the outcomes, of care for the population that a PIHP serves.
MDHHS Waiver Reviews
The Michigan Department of Health and Human Services (MDHHS) conducted a desk review for our region from June 13, 2022 through July 29, 2022. The review included the Habilitation Supports Waiver (HSW), the Waiver for Children with Serious Emotional Disturbance (SEDW) and the Children’s Waiver Program (CWP). MSHN was found in full compliance with the administrative section that included, among other things, review of policies and procedures for critical incidents, process for prior authorization and implementation of the quality improvement projects. In addition, record reviews and interviews were completed for beneficiaries on the HSW, CWP and SEDW. MSHN was found out of compliance for some of the protocols reviewed under each of the waivers, including some repeat findings from previous years. Some of the areas that were found out of compliance included the individual plan of service (IPOS) identifying goals/preferences, behavior treatment plans developed in accordance with the technical requirement, IPOS addressing needs identified in the assessment, IPOS identifying amount, scope and duration and provider qualifications. Noted among the strengths were that the clinical documentation was very strong, plans contained good transition of assessed needs into the plan of service, excellent coordination of care tools and strong individual plan of service tools. MSHN is required to submit a corrective action plan for each protocol that was not determined to be in compliance.
MDHHS Substance Use Services Review
MSHN received full compliance in all 13 areas of the Substance Use Disorder (SUD) Service Protocols reviewed by the Michigan Department of Health and Human Services (MDHHS) for Fiscal Year (FY) 2022. The areas included contracting, annual review of SUD services, specific block grant requirements, licensure of subcontractors, accreditation of subcontractors, subcontractor information to be retained, 12-month availability of services, primary care coordination, charitable choice, women's specialty services and fetal alcohol spectrum disorders prevention activities. There was no follow up or plan of correction required as a result of MSHN's full compliance with the protocols.